10 Things Your Orthodontist Won't Tell You

How you can make sure that all those months with a mouthful of braces will give you something to smile about.

1. "I might not really be an orthodontist." As Americans become ever more vain — witness the surge in popularity of plastic surgery and Botox treatments — it's no surprise that orthodontic procedures are on the rise. In 2002, the most recent year for which figures are available, orthodontic specialists treated some 4.6 million patients, according to a study in the Journal of Clinical Orthodontics — a 15% increase from 1998.

The real number is probably even higher, since that figure doesn't include patients who get orthodontic treatment from general dentists. Indeed, there is no law that prevents any old dentist from practicing orthodontics, and more and more dentists have been taking on orthodontics as a way to increase their business and client base.

How to make sure you're seeing a trained orthodontist? Look for one who is a member of the American Association of Orthodontists, which means he or she has an average of four years of dental school and a minimum of two years in an accredited residency program. Another good sign: voluntary certification with the American Board of Orthodontics (the group's Web site lists the organization's 2,026 members).

2. "My fees are negotiable . . ." Getting orthodontic work done isn't cheap. Minor adjustments, which might require treatment for three to six months, can cost between $600 and $1,500, but the median fee for full-scale treatment is $4,400 for a child and $4,800 for an adult — even more in pricey areas like New York City. If you have only partial insurance coverage or pay out-of-pocket, your bill can run high.

The good news, though, is that orthodontists offer a variety of payment plans. Many allow patients to pay through monthly installments with no interest, and with some orthodontists, you can negotiate the fee itself. Last spring Lisa Madsen, 39, sought the opinion of two orthodontists when she wanted to correct her bite. She felt more comfortable with the diagnosis of the first, though his treatment was more expensive. "I took the lower quote to the (first) orthodontist and said, 'Can you work with me?'" says Madsen, a stay-at-home mom in East Windsor, Conn. The result: He reduced his price by $300.

Some orthodontists will give a discount, usually 5 to 10%, if you pay the total in cash or with a credit card at the beginning of treatment. One woman even said her orthodontist offered a family discount of $300 per patient after the first one was treated.

3. ". . . but your final payment may not be so final." Most orthodontists charge an all-inclusive fee, which covers appointments and appliances from the beginning of treatment to the finish. But often patients end up shelling out hundreds of dollars more for broken appliances, retainers and appointments that extend beyond the scheduled treatment time. Orthodontists can also charge extra for X-rays, molds and missed appointments.

Just ask Marianne Eagan. After her son finished with braces four years ago, his orthodontist installed a permanent retainer on the back of his bottom teeth. But when it cracked a year and a half later, Eagan, 47, a research assistant in West Lafayette, Ind., had to pay $130 for a new removable retainer. When that one wore down, she had to pay for a second one. Not long after, she got braces herself and applied what she'd learned: When her orthodontist prescribed a splint to relax her jaw, she asked that the cost of a second splint, made to her new corrected teeth, be included in the contract and the original fee. Her advice: "Make sure you have everything written down in your contract." Also, read the fine print for extra costs — and leave a few hundred dollars in your budget for unforeseen bills.

4. "My treatment might not be the right treatment." Even orthodontists admit that straightening teeth is not an exact science. There are often clear approaches for common conditions, such as buck teeth and cross-bites, but more-complicated cases may involve judgment calls: whether it's necessary to pull teeth, for example, or to perform jaw surgery. The wrong approach could prolong treatment or make the problem worse.

In fact, if you go to two different orthodontists, you will very likely hear two different opinions about how to treat your teeth. If the orthodontist suggests invasive treatments, like pulling several teeth to create more space or jaw surgery, and you don't feel comfortable, it's a good idea to seek a second or even third opinion. In some cases there may be a less invasive treatment — polishing off some of the enamel between teeth, for example, to create more space. Be sure to inquire about alternative treatments and the possible risks each option poses. And ask the orthodontist if you can see pictures of cases similar to yours that were treated in the same manner. Or better yet, talk to former patients: Some orthodontists keep a list of people who have gone through the same treatment and are willing to talk to potential patients about their experience.

5. "Your child won't die if he doesn't get braces by age seven." The American Association of Orthodontists recommends that all children see an orthodontist by age seven. Advocates of early treatment argue that skeletal problems, such as a severe cross-bite or narrow jaw, are much easier to correct when the jaw is still growing, making a second treatment — often required when patients are in their teens — easier and quicker. Orthodontists sometimes recommend early treatment of severe cases of buck teeth or crowding, for example, on younger kids who feel embarrassed or are teased at school.

But some orthodontists say that not every child should be treated so early. Often, later treatment is still needed, which can drive up the total bill. And early treatment does not guarantee easier treatment later on. Sometimes adult teeth can grow in a way that creates a whole new set of problems. "Kids are such moving targets," says William Gray Grieve, a Eugene, Ore., orthodontist. Early treatment, he says, "may or may not make it easier later on."

If the orthodontist suggests preventative treatment, ask for a clear explanation of the treatment and why it can't wait. Also, assess the maturity of your child. Is he going to be cooperative? Can the child handle the possible pain? 6. "There's no guarantee your teeth will stay straight." As anyone who has ever worn a retainer can attest, orthodontists' pleas to patients to wear one often go unheeded. But without the use of a retainer, teeth can very quickly begin to revert to their old positions — sometimes within a week. And since orthodontists don't offer warranty-type programs, if the teeth move back, patients have little recourse beyond getting back in the chair and opening up their mouths and their wallets again.

Ten years ago, Debbie Michel, a 36-year-old journalist, wore braces for a year and a half to correct her overbite and crooked teeth. After getting her braces removed, she diligently wore her retainer for a year but then slowly started lapsing until she wasn't wearing it at all. Eight years later her teeth had shifted so much that she had to get braces again. The second treatment took seven months and cost $1,000.

Many orthodontists put permanent retainers on the back of their patients' lower teeth, but such fixtures don't work as well on the upper teeth. Most agree that to keep teeth in place, patients should wear their retainers regularly — almost all the time for the first two to six months after the braces come off, then every night for the rest of their lives.

7. "Someone might have worn these braces before you did." Some orthodontists use professionally sterilized and remanufactured brackets that have been worn by other people. Ortho-Cycle, a Hollywood, Fla., company that recycles brackets, bands and other orthodontic attachments, says it sells its products to about 2,000 U.S. dentists and orthodontists, who can save about 50% by using the recycled brackets.

Still, many orthodontists say that although there is no health risk in the practice, they opt to use new brackets because of the "gross out" factor. "It's more psychological than scientific," says Terry Pracht, president of the American Association of Orthodontists. If the idea of wearing used materials bothers you, ask your orthodontist if he or she uses recycled brackets.

8. "Braceless options are trendy, but they may not be the right choice." Invisalign, a teeth-alignment system that uses clear, thin, removable plastic aligners to move teeth, debuted in 1999 and has become popular in the past few years for obvious reasons: It is less noticeable than braces, and treatment typically lasts only for nine to 15 months.

But think twice about this option. It's expensive — ranging between $3,500 and $5,500, it can cost 25% more than braces — and it's not always the best treatment for many patients. Some orthodontists don't recommend it for complicated treatments like jaw realignments, though parent company Align Technology says that orthodontists and dentists who have more experience are starting to use it for increasingly complicated cases. And while Invisalign is removable, it still takes dedication: Patients have to wear the aligners at all times, except when eating, drinking, brushing or flossing their teeth.

Additionally, many orthodontists still aren't practiced at it. Lisa Madsen, the patient who negotiated her fee, had her heart set on Invisalign, and her primary dentist was ready to prescribe it for her. But when she found out he had handled only two cases before her, she balked. "I didn't want to be a guinea pig," she says. Madsen sought opinions from two orthodontists — both of whom said standard braces were better for her teeth.

9. "This process could take much longer than you think." Orthodontic treatments generally last anywhere from six months to three years, with most patients finishing within two years. Orthodontists typically set an estimated time frame at the beginning of treatment, but it can run longer than expected. This may be due to a misdiagnosis on the orthodontist's part, to the patient's failure to adhere to instructions or to an atypical growth pattern that may cause a teenage patient's teeth or jaws to move differently than anticipated.

When Brian Weiler's son Zac, now 16, started with braces four years ago, the orthodontist prescribed a straightforward 18-month treatment to correct his crooked teeth and slight overbite. But when one of Zac's adult teeth didn't come in on its own, he had to go through oral surgery midtreatment. The time frame also extended four months past the original estimate, costing Weiler some $250 more. "The whole experience was not pleasant emotionally and financially," says Weiler, of Duluth, Ga. "I felt like I was getting ripped off." His orthodontist blames the extra time on missed appointments and Weiler's delay in scheduling the surgery.

To best avoid such delays, adhere to the orthodontist's instructions. Also, if your child is being treated, ask your orthodontist to do a growth study: Taking X-rays of your child's hands and looking at the parents' and siblings' jaws can help gauge future growth speed and patterns.

10. "Oh, and by the way, this is going to hurt — a lot." It's no secret that orthodontic treatment can be painful. In most cases, the pain goes away two or three days after braces are put on or tightened, but some people are extremely sensitive to the pain. Just ask Robyn Perry, a stay-at-home mom in Loveland, Ohio. Seven weeks after getting braces put on, she had lost seven pounds because eating was so uncomfortable. "There have been days when I've been in tears telling my husband, 'I want them off,'" she says.

Soreness can generally be relieved with over-the-counter pain medicine, but you can also ask your orthodontist to tighten the bottom and upper braces at different appointments. Chewing sugarless gum, too, can help by stimulating ligaments in the teeth.

A possibly even more painful form of treatment is lingual braces, which attach to the backside of the teeth and which are popular among adults. But lingual braces can tear up the patient's tongue, and some patients also find it difficult to talk and may speak with a lisp for the first month of treatment. Within five days of having lingual braces put on, Javier Avila, a 45-year-old teacher in Brooklyn, N.Y., says his tongue had been scraped raw — and his students had to ask him to repeat himself. His solution? He called his orthodontist's emergency number and had him remove the braces on a Sunday morning.